Nutrition practices with a focus on parenteral nutrition in the context of enhanced recovery programs: An exploratory survey of gastrointestinal surgeons.

BACKGROUND & AIMS: Ensuring patients have adequate physiological reserves to meet the demands of major surgery may necessitate nutritional prehabilitation and perioperative medical nutrition therapy (MNT). Parenteral nutrition (PN) via central or peripheral routes is indicated when requirements cannot be met orally or enterally. While patients undergoing major gastrointestinal (GI) surgery are at high nutritional and catabolic risk, guidance on PN is limited in Enhanced Recovery After Surgery (ERAS) protocols. This survey-based study characterized MNT practices among GI surgeons, and the challenges and opportunities for MNT within the context of ERAS. METHODS: This on-line survey comprised questions and attitudinal statements centred on MNT, particularly PN, for major GI surgery patients, and encompassed the spectrum of the surgical pathway (prehabilitation to postoperative care). GI surgeons in Europe were invited to complete the survey. Respondents described their current clinical practices, while their perceptions, unmet needs, and opportunities to improve nutritional management were explored via Likert-scale responses to statements. RESULTS: GI surgeons (N = 130) from different centres in France, Germany, Italy, Poland, and Spain completed the survey. Enhanced recovery protocols (75%) and multidisciplinary nutritional care teams (72%) were established in the centres of most respondents; surgeons, dieticians/nutritionists, and nurses were most frequently involved in MNT. Nutritional risk screening was common in the centres surveyed prior to surgery (range: 62% in Italy to 96% in Poland) and undertaken less frequently postoperatively (range: 19% in Poland to 54% in Germany) with varied screening methods. Enteral nutrition insufficiency was the most common reason for prescribing PN (83%) and 56% of surgeons prescribed PN when enteral nutrition (EN) was not feasible. Overall, 71% of respondents agreed that peripherally administered PN (PPN), which does not require a central access route, lessens invasive procedures and benefits selected patients who are in a catabolic state, malnourished, or at nutritional/metabolic risk when oral intake/EN is insufficient. However, only 35% of surgeons used PPN in this scenario and only 47% utilized PPN when a central venous catheter is not available. Most surgeons (69%) agreed that PPN is in line with the ERAS concept of using minimally invasive approaches. The respondents raised a need for increasing awareness of PPN indications (81%), inclusion of PPN recommendations in clinical guidelines (79%), implementation of nutritional support teams (79%), and increased PPN-trained personnel (78%) to improve PPN delivery. CONCLUSIONS: PPN is perceived by surgeons (with ≥10 patients per month who receive PN) as a favourable strategy to support timely nutritional support in selected patients undergoing major GI surgery. However, from this clinical practice survey it seems PPN is underutilized in nutritional care practices. Findings from this survey of GI surgeons in Europe emphasize the need to improve early identification of patients who are malnourished or at nutritional/metabolic risk and integrate PPN into ERAS GI surgical pathways, within the framework of minimally invasive approaches.

Perioperative peripheral parenteral nutrition to support major gastrointestinal surgery: Expert opinion on treating the right patients at the right time.

BACKGROUND & AIMS: Patients undergoing major gastrointestinal surgery may be in particular need of nutritional therapy due to potential pre-existing disease-related malnutrition and the impact of surgical procedures. Peripheral parenteral nutrition (PPN), delivered via a peripheral catheter, is aligned with the Enhanced Recovery After Surgery (ERAS) concept of minimally invasive interventions where possible. However, uncertainties regarding perioperative PPN for patients undergoing major gastrointestinal surgery arise, in part, due to lack of clinical guidelines. This paper aims to provide practical guidance on perioperative PPN, within the framework of ERAS. METHODS: A panel of surgeons and nurses convened to identify knowledge gaps and share their best practice experience regarding PPN provision for patients undergoing major gastrointestinal surgery. Clinical needs were identified and addressed based on the panel's experience and a narrative review. RESULTS: Key topics addressed include how PPN can support ERAS nutritional recommendations, identifying gastrointestinal surgery patient subgroups who are likely to benefit from PPN, perioperative timepoints when PPN may be required, and optimizing the delivery of PPN. An algorithm to support the identification and management of patients' perioperative nutritional needs was developed. CONCLUSIONS: This paper aims to assist healthcare providers by addressing best practice questions related to the use of PPN during the critical perioperative period within the ERAS concept. This may facilitate timely nutritional intervention to help improve postoperative clinical outcomes and quality of life for patients undergoing major gastrointestinal surgery.